Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide

Transcription

1 Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide The Wound, Ostomy and Continence Nurses Society suggests the following format for bibliographic citations: Wound, Ostomy and Continence Nurses Society. (2017). Venous, arterial, and neuropathic lower-extremity wounds: Clinical resource guide. Mt. Laurel, NJ: Author. Copyright 2017 by the Wound, Ostomy and Continence Nurses Society (WOCN ). Date of publication: 10/10/17. No part of this publication may be reproduced, photocopied, or republished in any form, in whole or in part, without written permission of the WOCN Society.

2 Contents Contributors... 3 Introduction... 4 Purpose... 4 Assessment: Lower-Extremity Venous Disease (LEVD), Lower-Extremity Arterial Disease (LEAD), and Lower-Extremity Neuropathic Disease (LEND)... 5 History/Risk Factors... 5 Comorbid Conditions... 5 Wound Location... 6 Wound Characteristics... 6 Surrounding Skin... 6 Nails... 7 Complications... 7 Perfusion/Sensation of the Lower Extremity... 7 Pain... 7 Peripheral Pulses... 8 Common Non-Invasive Vascular Tests... 8 Screen for Loss of Protective Sensation... 8 Measures to Improve Venous Return... 9 Measures to Improve Tissue Perfusion... 9 Measures to Prevent Trauma... 9 Topical Therapy Goals Considerations/Options Adjunctive Therapy Indications for Referral to Other Healthcare Providers for Additional Evaluation and Treatment References

3 Contributors Originated By: Wound Committee, WOCN Society Original Publication Date: November 2009 Updated/Revised: April 2013: Wound Committee, WOCN Society September 2017: Phyllis A. Bonham, PhD, MSN, RN, CWOCN, DPNAP, FAAN Clinical Editor, WOCN Society Chair, Wound Guidelines Task Force, WOCN Society 3

4 Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide Introduction This Clinical Resource Guide updates the previous document, A Quick Reference Guide for Lower-Extremity Wounds: Venous, Arterial, and Neuropathic, which was developed by the Wound Committee of the Wound, Ostomy and Continence Nurses Society (WOCN, 2013). The guide is a synopsis of content derived from the WOCN Society s Clinical Practice Guideline Series for managing lower-extremity wounds due to venous, arterial, or neuropathic disease. Refer to the complete version of each Clinical Practice Guideline for more detailed, evidence-based information about the management of wounds in patients with lower-extremity venous, arterial, or neuropathic disease (WOCN, 2011, 2012, 2014): The guidelines are available in print or as an electronic mobile app from the WOCN Society s Bookstore ( Guideline for management of wounds in patients with lower-extremity venous disease (2011). Guideline for management of wounds in patients with lower-extremity neuropathic disease (2012). Guideline for management of wounds in patients with lower-extremity arterial disease (2014). Purpose This guide provides an overview of common assessment findings and key characteristics of the three most common types of lower-extremity wounds (i.e., venous, arterial, neuropathic). In addition, it includes a summary of the following information: measures to improve venous return and tissue perfusion; measures to prevent trauma; goals, considerations, and options for topical therapy; adjunctive therapies; and indications for referral to other healthcare providers for additional evaluation and treatment. 4

5 Lower-Extremity Venous Disease (LEVD) Wounds (WOCN, 2011) Advanced age. Obesity. Pregnancy. Thrombophilia. Systemic inflammation. Anticardiolipin antibody. Venous thromboembolism (VTE); phlebitis. Varicose veins. Pulmonary embolus. Sedentary lifestyle or occupation; reduced mobility. Simultaneous insufficiency of two out of three venous systems. Trauma; surgeries; leg fractures. Impaired calf muscle pump. Restricted range of motion of the ankle. Family history of venous disease. Injection drug user. Previous wound. Congestive heart failure. Lymphedema. Orthopedic procedures. Rheumatoid arthritis. Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide Lower-Extremity Arterial Disease (LEAD) Lower-Extremity Neuropathic Disease (LEND) Wounds (WOCN, 2014) Wounds (WOCN, 2012) Assessment: History/Risk Factors Advanced age. Smoking/tobacco use. Diabetes. Hyperlipidemia. Hypertension. Elevated homocysteine. Chronic renal insufficiency. Family history of cardiovascular disease. Ethnicity. Persistent Chlamydia pneumoniae infection. Periodontal disease. Assessment: Comorbid Conditions Cardiovascular disease; cerebrovascular disease; vascular procedures or surgeries. Sickle cell anemia. Obesity; metabolic syndrome. Arthritis. Spinal cord injury. Migraine. Atrial fibrillation. Human immunodeficiency virus (HIV). Low testosterone. 5 Advanced age; heredity. Alcoholism. Diabetes longer than 10 years; poor diabetes control; impaired glucose tolerance. Hansen s disease (leprosy); Charcot-Marie-Tooth disease. Smoking/tobacco use. Human immunodeficiency virus/acquired immunodeficiency syndrome and related drug therapies. Hypertension. Obesity. Raynaud s disease; scleroderma. Hyperthyroidism; hypothyroidism. Chronic obstructive pulmonary disease. Spinal cord injury; neuromuscular diseases. Abdominal, pelvic, and orthopedic procedures. Paraneoplastic disorders. Acromegaly/height. Exposure to heavy metals (e.g., lead, mercury, arsenic). Malabsorption syndrome due to bariatric surgery; celiac disease; vitamin deficiency (B 12, folate, niacin, thiamine); pernicious anemia. Loss of protective sensation; rigid foot deformities; gait abnormalities; history of previous ulcer/amputation. Lower-extremity arterial disease. Kidney disease.

6 Lower-Extremity Venous Disease (LEVD) Wounds (WOCN, 2011) The most typical location is superior to the medial malleolus, but wounds can be anywhere on the lower leg including back of the leg/posterior calf. Base: Ruddy red; granulation tissue and/or yellow adherent or loose slough may be present. Size: Variable; can be large. Depth: Usually shallow. Edges: Irregular; undermining or tunneling are uncommon. Exudate: Moderate to heavy. Infection: Not common. Edema: Pitting or non-pitting; worsens with prolonged standing or sitting with legs dependent. Scarring from previous wounds. Ankle flare; varicose veins. Hemosiderosis (i.e., brown staining). Lipodermatosclerosis. Atrophie blanche. Maceration; crusting; scaling. Temperature: Normally warm to touch. Localized elevation of skin temperature (greater than 4 F) measured at the ankle with a noncontact infrared thermometer is predictive of a wound. Lower-Extremity Arterial Disease (LEAD) Wounds (WOCN, 2014) Assessment: Wound Location Areas exposed to pressure, repetitive trauma, or rubbing from footwear are the most common locations: Lateral malleolus. Mid-tibial area (shin). Phalangeal heads, toe tips, or web spaces. Heels. Assessment: Wound Characteristics Base: Pale; granulation rarely present; necrosis common; eschar may be present. Size: Variable; often small. Depth: May be deep. Edges: Rolled; smooth; punched-out appearance; undermining may be present. Exudate: Minimal. Infection: Frequent (signs may be subtle). Pain: Common. Non-healing; wound often precipitated by minor trauma. Assessment: Surrounding Skin Pallor on elevation. Dependent rubor. Shiny, taut, thin, dry, and fragile. Hair loss over lower extremity. Atrophy of skin, subcutaneous tissue, and muscle. Edema: Atypical of arterial disease; localized edema may indicate infection. Temperature: Skin feels cool to touch. Lower-Extremity Neuropathic Disease (LEND) Wounds (WOCN, 2012) Plantar foot surface is the most typical location. Other common locations include: o Pressure points/sites of painless trauma/repetitive stress, over bony prominences (e.g., heels). o Metatarsal head (e.g., first metatarsal head and interphalangeal joint of great toe). o Dorsal and distal aspects of toes, inter-digital areas, interphalangeal joints. o Midfoot/fore-foot: Collapse of mid-foot structures with rocker-bottom foot suggests Charcot fracture. Base: Pale or pink; necrosis/eschar may be present. Size: Variable. Depth: Variable from shallow to exposed bone/tendon. Edges: Well-defined; smooth; undermining may be present. Shape: Usually round or oblong. Exudate: Usually small to moderate; foul odor and purulence indicate infection. Normal skin color. Anhidrosis; xerosis; fissures; maceration; tinea pedis. Callus over bony prominences (might cover a wound) and periwound; hemorrhage into a callus indicates ulceration underneath. Musculoskeletal/structural foot deformities. Erythema and induration may indicate infection/cellulitis. Edema: Unilateral edema with increased erythema, warmth, and a bounding pulse may indicate Charcot fracture. Temperature: Skin warm to touch; localized elevation of skin temperature greater than 2 C indicates inflammation. Diabetic skin markers: Dermopathy, necrobiosis lipoidica, acanthosis nigricans, bullosis diabeticorum. 6

7 Lower-Extremity Venous Disease (LEVD) Wounds (WOCN, 2011) Lower-Extremity Arterial Disease (LEAD) Wounds (WOCN, 2014) Lower-Extremity Neuropathic Disease (LEND) Wounds (WOCN, 2012) Assessment: Nails N/A Dystrophic. Dystrophic; hypertrophy. Onychomycosis; paronychia. Assessment: Complications Venous dermatitis (e.g., erythema, itching, vesicles, weeping, scaling, crusting, afebrile). Infection/Cellulitis (e.g., pain, erythema, swelling, induration, bulla, fever, leukocytosis). Variceal bleeding. Tinea pedis. Venous thromboembolism. Leg pain may be variable (e.g., severe, throbbing). Pain may be accompanied by complaints of leg heaviness. Leg pain worsens with dependency. Elevation relieves pain. Infection/Cellulitis (e.g., pain, edema, periwound fluctuance; or only a faint halo of erythema around the wound). Osteomyelitis (e.g., probe to bone). Gangrene (wet or dry). Assessment Perfusion/Sensation of the Lower Extremity: Pain Intermittent claudication is a classical sign and indicates 50% of the vessel is occluded (i.e., cramping, aching, fatigue, weakness, and/or pain in the calf, thigh, or buttock that occurs after walking/exercise and typically is relieved with 10 minutes rest). Resting, positional, or nocturnal pain may be present; resting pain indicates 90% of the vessel is occluded. Elevation exacerbates pain. Dependency relieves pain. Neuropathy and paresthesia may occur from ischemic nerve dysfunction. Acute limb ischemia: A sudden onset of the 6 P s (i.e., pain, pulselessness, pallor, paresthesia, paralysis, and polar [coldness]) indicates an acute embolism; and warrants an immediate referral to a vascular surgeon. Critical limb ischemia (CLI): Chronic rest pain; rest pain of the forefoot/toes. Ischemic non-healing wounds or gangrene are limb threatening with a high mortality rate and warrant referral to a vascular surgeon. Infection/Cellulitis. Arterial ischemia. Osteomyelitis. Charcot fracture (e.g., swelling, pain, erythema, localized temperature elevation of 3 7 C compared to an unaffected area). Gangrene. Pain may be superficial, deep, aching, stabbing, dull, sharp, burning, or cool. Decreased or altered sensitivity to touch occurs. Altered sensation not described as pain (e.g., numbness, warmth, prickling, tingling, shooting, pins and needles; stocking-glove pattern ) may be present. Pain may be worse at night. Allodynia (i.e., intolerance to normally painless stimuli such as bed sheets touching feet/legs) may occur. 7

8 Lower-Extremity Venous Disease Lower-Extremity Arterial Disease (LEVD) Wounds (WOCN, 2011) (LEAD) Wounds (WOCN, 2014) Assessment Perfusion/Sensation of the Lower Extremity: Peripheral Pulses Pulses are present and palpable. Pulses are absent or diminished (i.e., dorsalis pedis, posterior tibial). Femoral or popliteal bruits may be heard. Capillary refill: Normal (less than 3 seconds). Venous refill time: Shortened (less than 20 seconds). Ankle brachial index (ABI): Within normal limits ( ). Duplex scanning with ultrasound: Most reliable non-invasive test to diagnose anatomical and hemodynamic abnormalities and detect venous reflux. 8 Lower-Extremity Neuropathic Disease (LEND) Wounds (WOCN, 2012) Pulses are present and palpable. If co-existing LEAD is present: Pulses are absent or diminished (i.e., dorsalis pedis, posterior tibial); and femoral or popliteal bruits may be heard. Assessment Perfusion/Sensation of the Lower Extremity: Common Non-Invasive Vascular Tests Capillary refill: Abnormal (more than 3 seconds). Venous refill time: Prolonged (greater than 20 seconds). Ankle brachial index (ABI): o Non-compressible arteries: Unable to obliterate the pulse signal at cuff pressure greater than 250 mmhg. o Elevated: Greater than o Normal: Equal to/or greater than 1.00 o LEAD: Equal to/or less than o Borderline: Equal to/or less than o Severe ischemia: Equal to/or less than o Critical ischemia: Equal to/or less than Transcutaneous oxygen (TcPO2): Less than 40 mmhg is hypoxic; less than 30 mmhg is CLI. Toe brachial index (TBI): Less than 0.64 indicates LEAD. Toe pressure (TP): Less than 30 mmhg (less than 50 mmhg if diabetes present) indicates CLI. Assess for peripheral, sensory neuropathy using a 5.07/10 g Semmes-Weinstein monofilament. Capillary and venous refill times: Normal. ABI: LEAD, which often co-exists with neuropathic disease and diabetes should be ruled out. The ABI can be elevated greater than 1.30 or arteries can be non-compressible (i.e., unable to obliterate the pulse signal at cuff pressure greater than 250 mmhg), which indicates calcified ankle arteries. In such cases, a TP or TBI is indicated. o TBI: Less than 0.64 indicates LEAD. o TP: Less than 50 mmhg (if diabetes is present) indicates CLI and failure to heal. TcPO2: Less than 40 mmhg is hypoxic; less than 30 mmhg is CLI. Assessment Perfusion/Sensation of the Lower Extremity: Screen for Loss of Protective Sensation Assess light pressure sensation using a 5.07/ 10 g Semmes-Weinstein monofilament. Assess vibratory sensation using a 128 Hz tuning fork. Check deep tendon reflexes at the ankle and knee with a reflex hammer. Inability to feel the monofilament, diminished vibratory perception, and diminished reflexes indicate a loss of protective sensation and an increased risk of wounds. Assess light pressure sensation using a 5.07/10 g Semmes- Weinstein monofilament. Assess vibratory sensation using a 128 Hz tuning fork. Check deep tendon reflexes at the ankle and knee with a reflex hammer. Inability to feel the monofilament, diminished vibratory perception, and diminished reflexes indicate a loss of protective sensation and an increased risk of wounds.

9 Lower-Extremity Venous Disease (LEVD) Wounds (WOCN, 2011) Measures to Improve Venous Return Use compression therapy: mmhg compression at the ankle, if ABI is equal to/or greater than 0.80: o Multi-layer compression systems are more effective than single layer systems. o Consider intermittent pneumatic compression for patients who are immobile or need higher levels of compression than can be provided by wraps or stockings. Elevate legs above heart level: 30 minutes, 4 times per day. Consider medications (e.g., pentoxifylline) to improve blood flow. Increase exercise: Walking, calf muscle exercise, toe lifts, ankle flexion exercises. Avoid constricting garments, crossing legs, prolonged standing, and high heeled shoes. Stop smoking/tobacco use. Manage weight; healthy nutrition. Surgically obliterate damaged veins: Subfascial endoscopic perforator surgery (SEPS). Screen patients for LEAD by Doppler-derived ABI prior to application of compression stockings/bandages/wraps. Mixed venous/arterial disease: o Use reduced compression (23 30 mmhg) for patients with LEVD, wounds, and edema if ABI is less than 0.80 and equal to/or greater than o Do not apply compression if ABI is less than Lower-Extremity Arterial Disease (LEAD) Lower-Extremity Neuropathic Disease Wounds (WOCN, 2014) (LEND) Wounds (WOCN, 2012) Measures to Improve Tissue Perfusion Revascularize if possible. Revascularize if ischemic. Change lifestyle: Stop smoking/tobacco use; avoid Stop smoking/tobacco use. secondhand smoke, restrictive garments, and cold Maintain tight glucose/glycemic control; control temperatures. hypertension. Maintain proper hydration/nutrition. Engage in exercise that is adapted to prevent Maintain legs in a neutral or dependent position. injury. Increase physical activity: Walking; supervised Consider medications, as indicated. exercise minutes, 3 times per week. Use medications to control hypertension, hyperlipidemia, homocysteine levels, and diabetes; antiplatelets to improve blood cell movement through narrowed vessels. Control or reduce weight if obese. Measures to Prevent Trauma Use proper footwear; wear socks/stockings with shoes; obtain professional nail/callus care. Use pressure redistribution/offloading products/devices for heels, toes, and bony prominences, especially if bedbound or chairbound. Avoid chemical, thermal, and mechanical injury (e.g., no bare feet even in the house; no hot soaks or heating pads; no medicated corn pads). Self-inspect the lower extremities daily; promptly report injuries to the healthcare provider. Use reduced compression for mixed venous/arterial disease if the ABI is less than Do not apply compression if ABI is less than 0.50, ankle pressure is less than 70 mmhg, or TP is less than 50 mmhg. 9 Reduce shear stress and offload the at-risk neuropathic foot, and/or wounds (e.g., bedrest, total contact casts, walking splints, orthopedic shoes); use assistive devices for support, balance, and additional offloading. Use proper footwear; obtain routine professional nail/callus care. Use pressure redistribution/offloading products/devices for heels, toes, and bony prominences, especially if in bed or chairbound. Avoid chemical, thermal, and mechanical injury (e.g., no bare feet even in the house; no hot soaks or heating pads; no medicated corn pads; wear socks/stockings with shoes). Self-inspect the lower extremities on a daily basis.

10 Lower-Extremity Venous Disease (LEVD) Wounds (WOCN, 2011) Reduce and control edema. Attain/maintain intact skin; protect the periwound skin from drainage; absorb/manage exudate. Prevent trauma/injury. Prevent, promptly identify, and manage complications (e.g., infection/cellulitis; dermatitis/eczema). Promote wound healing; maintain moist wound surface. Reduce pain. Use absorptive dressings to control exudate. Treat infection: Use culture-guided antibiotic/antimicrobial therapy. o Consider topical antimicrobial/antibiotics for superficial infection. o Deep tissue infection/cellulitis warrants systemic treatment. Remove devitalized tissue. Avoid known skin irritants and allergens, tapes, and adhesives in patients with venous dermatitis/eczema. Use emollients such as petrolatum to manage dry, scaly skin. Consider use of barrier products to protect the periwound skin from excessive drainage and maceration. Identify and treat dermatitis/eczema (e.g., topical steroids 1 2 weeks). Consider topical analgesics for painful wound care/debridement. Lower-Extremity Arterial Disease (LEAD) Wounds (WOCN, 2014) Topical Therapy: Goals Prevent trauma/injury. Prevent, promptly identify, and manage complications (e.g., infection/cellulitis). Promote wound healing. Minimize pain. Preserve limb. Topical Therapy: Considerations/Options Avoid occlusive dressings: Use dressings that permit easy, frequent visualization of the wound. Aggressively treat infection. Dry, non-infected wounds with stable, fixed eschar, necrosis; or a stable blister: o Maintain, keep dry, protect, no debridement. o Assess perfusion status and signs of infection. Infected, necrotic wounds: o Refer for revascularization/surgical removal of necrotic tissue and antibiotic therapy. o Do not rely on topical antibiotics as the sole therapy to treat infected, ischemic wounds. o Promptly institute culture-guided systemic antibiotics for patients with CLI and evidence of limb infection or cellulitis, and/or infected wounds. Open/draining wounds with necrotic tissue: o Consider a closely monitored trial of autolytic or enzymatic debridement. Open/draining wounds with exposed bones or tendons: o Consider a carefully monitored trial of moist, nonocclusive, absorbent, dressings. Open/draining, non-necrotic wounds: o Consider moist wound healing with non-occlusive, absorbent dressings. Lower-Extremity Neuropathic Disease (LEND) Wounds (WOCN, 2012) Prevent trauma/injury. Prevent, promptly identify, and manage complications (e.g., infection/cellulitis or osteomyelitis). Promote wound healing. Keep the periwound dry while maintaining a moist wound bed. Minimize pain. Preserve limb. Use dressings that maintain a moist surface, absorb exudate, and allow easy visualization. Use occlusive dressings cautiously. Aggressively treat infection/cellulitis, including fungal infection. Do not rely on topical antimicrobials alone to treat cellulitis, but they could be used in conjunction with systemic antimicrobials; use of antimicrobials should be culture-guided. Debride focal callus to reduce pressure. Debride avascular/necrotic tissue in nonischemic wounds. 10

11 Lower-Extremity Venous Disease (LEVD) Wounds (WOCN, 2011) Skin substitutes. Electrical stimulation. Ultrasound. Dermatology referral for unresponsive dermatitis/eczema after 2 weeks of appropriate therapy. Vascular/surgical referral for: o Infection/Cellulitis. o Non-healing wound after 4 weeks of appropriate therapy. o Venous thromboembolism. o Variceal bleeding. o Intractable pain. o Atypical appearance or location of wound. Lower-Extremity Arterial Disease (LEAD) Wounds (WOCN, 2014) Adjunctive Therapy Hyperbaric oxygen therapy. Arterial flow augmentation (i.e., intermittent pneumatic compression). Electrotherapy. Low frequency ultrasound. Spinal cord stimulation. Lower-Extremity Neuropathic Disease (LEND) Wounds (WOCN, 2012) Hyperbaric oxygen therapy. Skin substitutes. Topical negative pressure. Growth factor therapy. Surgery to correct structural deformities. Surgical debridement/implantation of antibiotic beads, spacers, or gels. Pain management specialists. Indications for Referral to Other Healthcare Providers for Additional Evaluation and Treatment Vascular/surgical referral: o Infected, ischemic wounds: Clinical signs of infection/cellulitis or suspected osteomyelitis. o Atypical appearance or location of wound. o Intractable pain. o Wounds and/or edema in mixed venous/arterial disease that fail to respond to compression therapy or worsen. o Absence of both dorsalis pedis and posterior tibial pulses. o ABI less than 0.90 plus one or more of the following: Wound fails to improve with 2 to 4 weeks of appropriate therapy, severe ischemic pain, and/or intermittent claudication. o ABI less than o ABI greater than 1.30 or non-compressible arteries. Urgent vascular/surgical referral for symptoms of acute limb ischemia; CLI (ABI less than 0.40; ankle pressure less than 50 mmhg; TP less than 30 mmhg/or less than 50 mmhg if diabetes present; TcPO2 less than 30 mmhg); and/or gangrene. Refer patients who smoke/use tobacco and have a loss of protective sensation to foot care specialists and for tobacco cessation education/counselling. Refer patients with gait abnormalities to a qualified pedorthic professional for shoe or device customization. Vascular/surgical referral: o Infection/Cellulitis or suspected osteomyelitis (i.e., probe to the bone). o Atypical appearance or location of wound. o Symptoms/new onset of Charcot fracture. o Musculoskeletal/structural foot deformities. o ABI less than 0.90 and no response to 2 to 4 weeks of conservative wound care. o ABI less than o ABI greater than 1.30 or non-compressible arteries. Urgent vascular/surgical referral for symptoms of acute limb ischemia, CLI, and/or gangrene. 11

12 References Wound, Ostomy and Continence Nurses Society. (2011). Guideline for management of wounds in patients with lower-extremity venous disease. WOCN Clinical Practice Guideline Series 4. Mt. Laurel, NJ: Author. Wound, Ostomy and Continence Nurses Society. (2012). Guideline for management of wounds in patients with lower-extremity neuropathic disease. WOCN Clinical Practice Guideline Series 3. Mt. Laurel, NJ: Author. Wound, Ostomy and Continence Nurses Society. (2013). A quick reference guide for lowerextremity wounds: Venous, arterial, and neuropathic. Mt. Laurel, NJ: Author. Wound, Ostomy and Continence Nurses Society. (2014). Guideline for management of wounds in patients with lower-extremity arterial disease. WOCN Clinical Practice Guideline Series 1. Mt. Laurel, NJ: Author. 12